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The Irene R. Weidman Charitable Trust Grant Application
"
*
" indicates required fields
Organization Name
*
Required
Tax ID Number
*
Required
Address
*
Required
Street Address
Address Line 2
City
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VI
VT
VA
WA
WV
WI
WY
AA
AE
AP
State
ZIP Code
Address to mail funds if different than above
Street Address
Address Line 2
City
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VI
VT
VA
WA
WV
WI
WY
AA
AE
AP
State
ZIP Code
Contact Person's Name
*
Required
First
Last
Contact Person's Title
Contact Person's Phone Number
*
Required
Contact Person's Email
*
Required
Organization's Website
Mission Statement
*
Required
Dollar Amount Requested
*
Required
Is your organization located, or will the grant funds be used, within a 15 mile radius of the intersection of Main and State Streets, Ephrata PA?
*
Required
Yes
No
Description of Request
*
Required
Files to Upload
Cover Letter Outlining Request
*
Required
Accepted file types: jpg, png, pdf, doc, docx, csv, xls, xlsx, rtf, txt, ppt, pptx, Max. file size: 31 MB.
501(c) (3)
*
Required
Accepted file types: jpg, png, pdf, doc, docx, csv, xls, xlsx, rtf, txt, ppt, pptx, Max. file size: 31 MB.
Most recent audited financial statements
*
Required
Accepted file types: jpg, png, pdf, doc, docx, csv, xls, xlsx, rtf, txt, ppt, pptx, Max. file size: 31 MB.
Organization’s Budget
*
Required
Accepted file types: jpg, png, pdf, doc, docx, csv, xls, xlsx, rtf, txt, ppt, pptx, Max. file size: 31 MB.
Other Documents
Drop files here or
Select files
Accepted file types: jpg, png, pdf, doc, docx, csv, xls, xlsx, rtf, txt, ppt, pptx, Max. file size: 31 MB, Max. files: 10.
Consent
*
Required
I certify that any funds received will only be used towards the projects described above
Phone
This field is for validation purposes and should be left unchanged.
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